Background: Atherosclerosis of the brachiocephalic arteries is one of the leading causes of ischemic cerebrovascular disorders, which is based on a complex, multi-stage process regulated by epigenetic mechanisms. The latter, in particular, include changes in the expression of molecules such as microRNAs - small (on average, 22 nucleotides) non-coding RNA sequences that are heavily involved in most physiological and pathological processes.
Objective: The aim of the study was to evaluate the expression of miR-126-5p/-3p, miR-21-5p/-3p, miR-33a-5p/-3p, miR-29a-5p/-3p in relation to association with clinical cerebrovascular events and to identify differences in the expression pattern depending on the performed transluminal balloon angioplasty with carotid artery stenting for hemodynamically significant carotid stenosis.
Patients and methods: Our prospective study included 80 patients [average age - 66 years, men - 44 (55%)] with cerebral atherosclerosis of varying severity who were admitted to the vascular departments of the 'Research Center of Neurology' (Moscow). Transluminal balloon angioplasty with stenting (TBAS) of the carotid artery was performed in 33 patients [in 14 (42%) patients - for symptomatic stenosis]. All patients underwent thorough clinical and neurological examination, laboratory and instrumental research methods, including isolation and analysis of microRNA expression (miR-126-5p/-3p, miR-21-5p/-3p, miR-33a-5p/-3p, miR-29a-5p/-3p).
Results: The microRNA expression pattern was significantly different in the patients who underwent TBAS: the levels of miR-126-5p/-3p and miR-29a-5p were statistically significantly lower, and those of miR-33a-5p/-3p higher compared with the patients who did not undergo angiosurgery. A multivariate linear regression model that included the expression of all the microRNAs studied identified miR-126-5p and miR-21-5p as statistically significant independent predictors of the degree of carotid artery stenosis.
Conclusion: The expression of a number of atherogenic microRNAs in patients who underwent transluminal angioplasty with carotid artery stenting appeared to be of a differentiated nature. The most significant biomarker was the expression level of miR-126-5p, which is associated, among other things, with the degree of carotid stenosis.
Presented in the article are the results of an international, multicenter, randomized, doubleblind, two-stage, two-sequence cross-over comparative study of the efficacy and safety of arginine sodium succinate (Unifuzol®) and pentoxifylline in the form of intravenous infusions in patients with stage II PAD according to the classification of A.V. Pokrovsky.
Objective: The study was planned to demonstrate superiority of treatment with arginine sodium succinate to pentoxifylline based on the absolute change in the maximum walking distance and pain-free walking distance on the day next to the end of the treatment compared to the baseline level.
Patients and methods: A total of 229 patients were randomized in a 1:1 ratio to each treatment sequence. The primary efficacy parameters were: absolute (in meters) and relative (in %) increase in maximal walking distance and pain-free walking distance in the treadmill test on the day next to completion of therapy with the study drugs compared with the baseline level.
Results and discussion: A comparative analysis revealed a significant difference in the increase of the maximum walking distance after a 12-day course of treatment with arginine sodium succinate and the comparative drug (29.4 and 19.6 m, respectively), with the absolute difference amounting to 9.8 m (95% CI 5.67-13.88). Thus, arginine sodium succinate turned out to be one and a half times more effective than pentoxifylline. The difference in pain-free walking distance, the average increase of which in the group treated with arginine sodium succinate was 23.9 m, and in the comparison group - 16.1 m, also showed higher efficacy of arginine sodium succinate.
Conclusion: According to the results of the analysis, for all parameters of effectiveness, a statistically significant superiority was shown in patients with stage II obliterating atherosclerosis of the vessels of the lower extremities treated with arginine sodium succinate compared to pentoxifylline.
Background: The problem of atherosclerotic lesions of lower limb arteries and chronic critical ischemia is currently important, requiring the development and implementation into clinical practice of modern, safe and accurate methods of examination, thus making it possible to more precisely plan and evaluate the outcomes of the operations performed.
Objective: This study sought to determine the possibility of using the technique of ultrasound examination (duplex scanning) of the pedal arteries, measuring dopplerographic parameters of quantitative assessment of blood flow in the angiosomes of the foot in patients with chronic critical lower limb ischemia, depending on severity, and alterations therein following revascularization.
Patients and methods: We examined 31 patients with atherosclerotic occlusive lesions of lower extremity arteries. Of these, 3 patients had III stage chronic limb ischemia according to the Fontaine-Pokrovsky classification and 28 had IV stage ischemia. Twelve patients were diagnosed as having type 2 diabetes mellitus. The patients' age ranged from 56 to 93 years, with a male-to-female ratio of 26:5. The main dopplerographic parameters assessed were as follows: pulse waveform, ante- or retrograde blood flow in the artery examined, peak systolic blood flow velocity, maximal systolic acceleration, and acceleration time.
Results: We consider that the main advantage of using duplex scanning of the pedal arteries with measuring the maximal blood-flow acceleration is a possibility to assess namely the severity of foot ischemia. A strong inverse correlation was found between the maximum acceleration measured in pedal arteries and the severity of lower limb ischemia, as assessed according to the modified Rutherford scoring scheme (R2=0.78). It was shown that the proposed method of diagnosis is accurate and non-invasive, making it possible without additional devices and preparations to assess the result of revascularization in the operating room immediately after surgery.
Conclusion: This pilot study allows us to conclude that duplex scanning of the pedal arteries with the measurement of the maximum blood flow acceleration is a promising rapid alternative method of diagnosing peripheral artery disease and assessing efficacy of revascularization performed, especially in patients with uninformative values of the ankle-brachial index and impossibility to measure the finger pressure index.
Background: Conservative management of patients after reconstructive vascular operations remains an important and widely discussed problem of modern medicine.
Objective: This study was aimed at evaluating efficacy and safety of combined administration of aspirin and low-dose rivaroxaban in patients with atherosclerosis who underwent reconstructive operations on arteries below the inguinal ligament for chronic critical lower limb ischemia.
Patients and methods: Our prospective cohort study included a total of 182 patients with atherosclerosis and chronic critical lower limb ischemia. The patients' age ranged from 40 to 95 years (mean age 65.3±8.1 years). The period of the study was from 2018 to 2021. All patients underwent femoropopliteal bypass graft surgery with a distal anastomosis both above and below the knee-joint fissure, with either a reversed autovein or a synthetic graft used as a shunt. The patients were divided into 4 groups depending on the type of operation and prescribed therapy in the postoperative period. Control was carried out by means of clinical examination and duplex ultrasound angioscanning of lower-limb arteries after 30 days, as well as at 3, 6 and 12 postoperative months.
Results: An unfavorable clinical outcome was defined as the development of either single or various combinations of such conditions as acute limb ischemia, major amputation, shunt thrombosis, acute myocardial infarction, acute cerebrovascular accident, cardiovascular death. They were reveled in the remote period after surgery (from 30 days to 12 month) in 4 (8.3%) Group 1 patients, 6 (13.6%) Group 2 patients, 6 (13.3%) Group 3 patients and in 11 (24.4%) Group 4 patients. Besides, there was 1 (2.6%) major gastrointestinal bleeding in Group 2, with no significant hemorrhagic events revealed in other groups (p=NS).
Conclusion: Low-dose rivaroxaban combined with aspirin proved effective in preventing major adverse limb events and safe as to hemorrhagic complications compared with a combination of aspirin and clopidogrel in patients after revascularization of lower extremities for chronic critical limb ischemia.
Objective: The aim of this study was to investigate changes in the distal aorta after surgical treatment of patients with acute type A aortic dissection in the remote postoperative period.
Patients and methods: Our prospective study included a total of 116 patients presenting with acute type A aortic dissection and operated on at the Samara Regional Clinical Cardiological Dispensary named after V.P. Polyakov (54 patients subjected to prosthetic repair of the ascending aorta either alone or in a combination with aortic hemiarch replacement - Group 1) and at the Petrovsky National Research Center of Surgery (62 patients undergoing hybrid surgery - Group 2) from 2013 to 2022. The condition of the distal aorta was studied before and in the remote period after surgery (48.7±30.1 months).
Results: In the late postoperative period, thrombosis of the false lumen most often occurred in the proximal descending aorta, observed in 21% and 67% of Group 1 and Group 2 patients, respectively (p<0.01). Negative remodeling of the descending aorta in the remote period occurred in 59% of Group 1 patients, with no negative remodeling observed in Group 2 patients (p<0.001). Group 2 patients were found to have only positive remodeling or maintain the stable condition. Risk factors for false lumen functioning in the remote postoperative period, regardless of the type of surgery, were as follows: patient age <50 years (p=0.002) for the thoracic descending aorta, the number of secondary fenestrations greater than 5 in the abdominal aorta (p=0.001), as well as extension of dissection to branches of the aortic arch for the thoracic aorta after proximal 'limited' aortic reconstruction (p=0.002).
Conclusions: In patients with acute type A aortic dissection, hybrid operations more often result in thrombosis of the false lumen in the thoracic descending aorta and are not accompanied by negative remodeling. Risk factors for false lumen functioning in the thoracic aorta after surgery are as follows: patient age under 50 years, propagation of dissection to branches of the aortic arch (after proximal 'limited' aortic reconstructions); in the abdominal aorta - the number of secondary fenestrations in this section >5.
The authors herein share their experience with surgical treatment of arteriovenous fistulas (AVF), describing standard diagnostic measures and possible methods of management of this pathology, as well as analyzing the known methods of treatment of post-traumatic AVFs in a specialized vascular hospital.
Objective: To determine the most effective method of surgical treatment of patients with posttraumatic AVFs in the early period of wound disease.
Patients and methods: From 2021 to 2023, a total of 58 patients with posttraumatic AVFs of the extremities were treated in the vascular centers of the National Medical Research Center of Surgery named after A.V. Vishnevsky and National Medical Research Center of High Medical Technologies - Central Military Clinical Hospital named after A.A. Vishnevsky'. Of these, 51 (88%) patients were diagnosed as having lower-limb vascular pathology and 7 (12%) had upper-limb pathology. 29 (50%) patients underwent X-ray endovascular methods of treatment, 26 (44.8%) patients were subjected to open surgical intervention, and 3 (5.2%) victims were found to have spontaneous closure of the AVF.
Results: Endovascular methods of treatment included: implantation of stent grafts in 20 (34.5%) patients, embolization with microcoils in 7 (12%) cases, and 'multilayer' stenting of the AVF zone in 2 (3.4%). Open surgical methods of treatment were as follows: arterial prosthetic repair in 20 (34.5%) patients, ligation of the arteriovenous fistula itself in 3 (5.1%) patients, autovenous plastic surgery of the arterial defect in 1 (1.7%) case, fistula disconnection with single-suture closure of the venous wall in 1 (1.7%), and resection of the damaged segment of the popliteal artery with an end-to-end anastomosis in 1 (1.7%). During the postoperative follow-up period, 3 complications developed in each study group. After endovascular treatment, these were 'local' complications in the form of thrombosis and implant dislocation in 2 patients and a recurrence of the functioning AVF in 1 case. After open surgery: wound suppuration in 1 patient, arrosive bleeding in 1 patient (with the resulting limb amputation), and a relapse of the AVF in 1 case.
Conclusion: Each case of posttraumatic arteriovenous fistula has an individual approach to treatment. Surgical decision-making depends on such factors as the duration of AVF, diameter, localization, level of arterialization of venous blood flow, severity of changes in the walls of the affected arteries and veins. All posttraumatic arteriovenous fistulas should be treated surgically in a specialized vascular center with all modern technologies.
A clinical case of massive arterial bleeding from the brachiocephalic trunk in the tracheostomy area against the background of the formation of a tracheoarterial fistula is presented. Issues under discussion: the choice of examination methods and surgical treatment tactics in a multidisciplinary hospital as part of a multidisciplinary team in patients with such a life-threatening complication.
Objective: This study aimed to analyze the results of using custom-made fenestrated stent grafts and physician-modified stent grafts.
Patients and methods: We retrospectively analyzed a total of 26 patients with unfavorable neck anatomy operated on in the Republican Cardiological Center of Ufa and the Federal State Budgetary Institution 'Clinical Hospital' of the Administrative Directorate of the President of the Russian Federation. The patients were divided into 2 groups according to the method of fenestration formation: Group I receiving a custom-made device (n=12) and Group II receiving a physician-modified device (n=14).
Results: The average number of fenestrations in the first group was 2.7±0.6 per patient and in the second group 1.5±0.7 per patient. The success rate of implantation of the aortic component was 100% in both groups. In the first group, bridge graft implantation success was 96.3% (26 out of 27). Bridge graft implantation success in the second group was 95.4% (21 out of 22). Control MSCT revealed 2 endoleaks (16.7%) in the first group and 1 endoleak (7.1%) in the second group. In the first group, type IV endoleak was encountered in one case and type Ib endoleak in another.
Conclusion: The first results of using custom-made and physician-modified fenestrated stent grafts showed the data comparable with those from other clinics and indicated common complications and causes of repeat interventions.
Presented herein is a clinical case concerning a hybrid approach to the treatment of a 67-year-old patient with terminal abdominal aortic stenosis and prolonged occlusion of the femoral-popliteal segment of the left lower limb with the development of stage 4 chronic limb ischemia. The patient underwent a hybrid surgical procedure: complex endovascular reconstruction of the terminal aorta and iliac arteries (CERAB) with simultaneous left-sided autovenous femoral-tibial bypass grafting with good immediate and medium-term results.
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